Myasthenia gravis is an autoimmune disease associated with several autoantibodies that attack the neuromuscular junction. Some cases are associated with thymoma. The hallmark of management is individualized immunosuppressive therapy.

Background: Generalized myasthenia gravis (MG) with antibodies against the acetylcholine receptor is a chronic disease causing muscle weakness. Access to novel treatments warrants authoritative treatment recommendations. The Nordic countries have similar, comprehensive health systems, mandatory health registers, and extensive MG research.Methods: MG experts and patient representatives from the five Nordic countries formed a working group to prepare treatment guidance for MG based on a systematic literature search and consensus meetings.Results: Pyridostigmine represents the first‐line symptomatic treatment, while ambenonium and beta adrenergic agonists are second‐line options. Early thymectomy should be undertaken if a thymoma, and in non‐thymoma patients up to the age of 50–65 years if not obtaining remission on symptomatic treatment. Most patients need immunosuppressive drug treatment. Combining corticosteroids at the lowest possible dose with azathioprine is recommended, rituximab being an alternative first‐line option. Mycophenolate, methotrexate, and tacrolimus represent second‐line immunosuppression. Plasma exchange and intravenous immunoglobulin are used for myasthenic crises and acute exacerbations. Novel complement inhibitors and FcRn blockers are effective and fast‐acting treatments with promising safety profiles. Their use depends on local availability, refunding policies, and cost–benefit analyses. Adapted physical training is recommended. Planning of pregnancies with optimal treatment, information, and awareness of neonatal MG is necessary. Social support and adaptation of work and daily life activities are recommended.Conclusions: Successful treatment of MG rests on timely combination of different interventions. Due to spontaneous disease fluctuations, comorbidities, and changes in life conditions, regular long‐term specialized follow‐up is needed. Most patients do reasonably well but there is room for further improvement. Novel treatments are promising, though subject to restricted access due to costs.

Myasthenia gravis (MG) with onset below 50 years, thymic hyperplasia and acetylcholine receptor (AChR) antibodies is more common in females than in males. For a relatively large group of MG patients, pregnancy represents therefore an important question. The muscle weakness, the circulating autoantibodies, the hyperplastic thymus, the MG drug treatment, and any autoimmune comorbidity may all influence both mother and child health during pregnancy and also during breastfeeding in the postpartum period. Mother's MG remains stable in most patients during pregnancy. Pyridostigmine, prednisolone, and azathioprine are regarded as safe during pregnancy. Mycophenolate, methotrexate and cyclophosphamide are teratogenic and should not be used by women with the potential to become pregnant. Rituximab should not be given during the last few months before conception and not during pregnancy. Intravenous immunoglobulin and plasma exchange can be used for exacerbations or when need for intensified therapy. Pregnancies in MG women are usually without complications. Their fertility is near normal. Vaginal delivery is recommended. MG patients have an increased rate of Cesarean section, partly due to their muscle weakness and to avoid exhaustion, partly as a precaution that is often unnecessary. Around 10% of the newborn develop neonatal myasthenia during the first few days after birth. This is transient and usually mild with some sucking and swallowing difficulties. In rare cases, transplacental transfer of AChR antibodies leads to permanent muscle weakness in the child, and arthrogryposis with joint contractures. Repeated spontaneous abortions have been described due to AChR antibodies. MG women should always give birth at hospitals with experience in newborn intensive care. MG does not represent a reason for not having children, and the patients should be supported in their wish of becoming pregnant.